Walgreens has announced that it is teaming up with MDLive to offer virtual healthcare visits through their pharmacy mobile app. Walgreens customers have been able to connect with pharmacist and Walgreens staff via the app for several years, but a new expanded telemedical service will soon be offered to Walgreens customers in their California and Michigan retail outlets. Customers, or patients, will be able to consult with physicians virtually about routine acute conditions. Walgreens’ management plans to expand the new service to their retail centers in other states.

Telemedicine has found considerable success and acceptance as a tool to connect patients located in rural areas with medical specialist in urban medical centers, bringing much needed neurological and other medical specialties to patients previously denied convenient access to advanced, specialized care. Time sensitive virtual treatment for stroke and other neurological ailments are now readily available to patients regardless of where they live, saving valuable time, improving patient outcomes and saving lives.

But the expansion of telecommunication technology to broader telehealth applications is just beginning to be introduced to consumers through retail outlets and the workplace and is likely to disrupt the normal delineation of services in the medical care industry.

Walgreens is being joined by competitors CVS and Target in an aggressive entry into virtual, in-store healthcare clinics through partnerships with a growing number of emerging or established healthcare providers. Kaiser Permanente, a leading clinical healthcare provider, is now experiencing nearly half of their patient encounters virtually, in their Northern California clinics, which has grown from 4.1 million visits in 2008 to approximately 10.5 million at the end of 2013. Permanente Medical Group CEO, Robert Pearl is predicting that Kaiser’s virtual clinic visits will exceed in-person encounters by 2016.

Typically consumers use retail clinics for services such as vaccines, strep throat tests and treatments for other common maladies but the new entrants into the retail telehealth market are predicting that patients will also use the new virtual clinics for pediatric care, well-woman care, family planning and chronic-illness management.

Investors in the expanded retail telehealth market are banking on consumer/patients to continue to respond positively to the convenience and cost savings offered by telemedicine in order to successfully navigate through the start-up to profitability curve. It has been predicted for nearly a decade that advances in telecommunication technology would lead to a vastly different and innovative medical care delivery model. It would appear that the predictions are well on the way to becoming reality.

This is the final blog in a series chronicling the development of AcuteCare Telemedicine (ACT). Much of this reflection involves lessons learned at a past Annual Meeting of the American Telemedicine Association (ATA). What follows is an amalgam of facts, experience and opinions culled from that fantastic symposium and honed by hindsight. Today’s blog will focus on legal and technology issues.

As stated in Part 4 of this series, Running the Business, there are a myriad of issues confronting physician-entrepreneurs when establishing a telemedicine service. Physicians are trained to provide medical care, yet this is a technology business. Therefore, an overview of contracts and technology is paramount.

Contracts have to be written to fit the specific needs of each client. However, it is appropriate to have a boilerplate document that addresses both general contract features (e.g. non-malfeasance, non-compete, etc) as well as telemedicine specific features (e.g. the type of encounters covered, the times covered if not 24/7, etc). The contract should stipulate that the telemedicine providerwill determine appropriate use of telepresence. If used for routine consults, a maximum number of encounters to be provided per time period can be stipulated in lieu of a sliding fee schedule. It is probably good practice to make it the obligation of the client hospital to maintain HIPAA compliance (e.g. not having the patient in an ED hallway) and assure patient identity prior to consultation (requiring the RN to show you the patient’s wristband ID [never thought of that, did you?]). The contract should also clearly state who is responsible for technical support (see technology below).

A few more legal issues bear mentioning. CMS may allow the originating site (i.e. telemedicine corporation) to do one time M.D. credentialing versus repeating at every client hospital. While CMS doesn’t apparently distinguish between corporations and health care centers, this credentialing allowance is likely in deference to university hospitals proving remote presence. It would ultimately be up to the client hospital to accept the remote provider’s credentialing process in lieu of their own. Every business partner who has access to patient related data must have a HIPAA oriented contract. A written statement should be obtained from one’s malpractice provider documenting coverage for each state in which treating physicians are licensed.

There are ever expanding options for remote presence technology. Purchase or leasing of proprietary hardware by the client hospital has been the standard. This is attractive because the telemedicine provider makes more money and the hospital experiences lower upfront costs. In the long run, this is actually more expensive for the hospital, and obscures whether the service is providing medical care or simply technology. There are less expensive alternatives, including subscribiptions to web-based software for use with the clients preexisting resources (i.e. PC, webcam, ethernet, hospital IT department). However, choosing this technology will affect reliability; IT departments may not have dealt with the paradigm of providing 24 hour, secure, immediate, unfaltering access for physicians from remote sites.

The better alternative is the purchase of hardware and software from vendors dedicated to telemedicine technology and IT support. It has been demonstrated that client hospitals with a financial investment in the technology are more likely to use it. This leads to more encounters and a reinforcement of the value of the entire endeavor. The technology available varies from fairly fixed COWs (Computers On Wheels) to fully autonomous robots that can move independently between and within rooms, with one-time costs ranging from $25-60,000. Hospitals may then choose the technology based on budget, IT support, software and value added features (e.g. stethoscopes, government grant subsidies, etc). Hardware should undergo scheduled replacement (i.e. laptops every 3 years). Either a dedicated T1 line or reliable Wi-Fi are mandatory. Regardless of the technology employed, patient interaction should be standardized across sites by a telemedicine provider. This normalizes the decision process and improves remote partner (RN, MD) facilitation of exam at the bedside. A written protocol (e.g. NIHSS) is also useful. Finally, as technology continues to proliferate, the future holds great potential for interoperability of these systems with electronic health records, further revolutionizing patient care through telemedicine solutions.

Establishing a telemedicine service is a challenging yet extremely rewarding endeavor that will ultimately contribute to an overall higher standard of patient care. Armed with new insights culled from these experiences, AcuteCare Telemedicine is moving towards the future with consideration for the procedures and mechanics that are obligatory for success, yet not part of standard medical school curricula.